Provider Demographics
NPI:1073835880
Name:TEDROW, MARK STEVEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVEN
Last Name:TEDROW
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 S WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6712
Mailing Address - Country:US
Mailing Address - Phone:815-235-4299
Mailing Address - Fax:815-233-4675
Practice Address - Street 1:1880 S WEST AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6712
Practice Address - Country:US
Practice Address - Phone:815-235-4299
Practice Address - Fax:815-233-4675
Is Sole Proprietor?:No
Enumeration Date:2010-02-20
Last Update Date:2010-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-0334231835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist